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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 07/29/2022
Date Signed: 07/29/2022 06:29:44 PM

Document Has Been Signed on 07/29/2022 06:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:PINK, TILLMAN JR.FACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(805) 646-2402
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 14DATE:
07/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Nicole ZandersTIME COMPLETED:
06:15 PM
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Licensing Program Analyst (LPA) JoAnn Rosales arrived at the facility to conduct a Case Management - Incident visit and to continue the Post Licensing visit started on 4/21/22.

During facility tour with staff Nicole Zanders at 11:44 am LPA observed that the facility continues to use video camera's located in the common areas inside the facility. LPA advised staff Zanders that an updated Plan of Operation and Admission Agreement needs to be submitted for licensing review and approval prior to the use of the video cameras.

During facility tour with staff Zanders at 11:47 am LPA observed a sink and toilet in a storage room which is not on the facility sketch.

During facility tour with staff Zanders at 11:49 am LPA observed lotion and shampoo in an unlocked resident room accessible to residents. Administrator stated that the resident that was in that room recently passed away.

During facility tour with staff Zanders at 11:51 am LPA observed a wall put up in the medication room which is not on the facility sketch.

During facility tour with staff Zanders at 11:52 am LPA observed isopropyl alcohol, povidone-iodine prep pads, T/Gel therapeutic shampoo, nail polish remover, triple antibiotic ointment, wound cleanser, wound & burn dressing in an unlocked cabinet in a training room accessible to residents. Staff stated that the items should have been in the locked medication room.

During facility tour with staff Zanders at 12:05 pm LPA observed asepticare aerosol-disinfectant viruciden in an upstairs bathroom accessible to residents.

Continued on 809C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 07/29/2022
NARRATIVE
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During facility tour with staff Zanders at 12:07 pm LPA observed lotion, toothpaste, deodorant, mascara, makeup, and razors in an upstairs staff bathroom accessible to residents. Staff stated that the door should have been locked.

During facility tour with staff Zanders at 12:12 pm LPA observed Turf Builder weed & feed, fertilizer, and gardening tools in a backyard shed accessible to residents.

LPA reviewed resident medications with staff Zanders and staff #1 (S1) starting at 1:32 pm. During a review of resident medications LPA observed that R2 did not receive their morning medications on 7/1/22 through 7/6/22 and again on 7/10/12 through 7/12/22 as S1 stated that R2 eloped from the facility. Staff Zanders stated that on 7/10/22 R2 signed out that they were leaving. Staff Zanders stated that they were not working on that day. At 3:20 pm LPA Rosales spoke with S2 who stated that R2 indicated on 7/10/12 that staff Zanders stated that it was ok for R2 to leave the facility. S2 stated that they asked R2 to sign out when they leave the facility. S2 stated that they gave R2 their morning medications before they left. S2 stated that when they returned to work the next day R2 had not returned to the facility from the prior day. S2 stated that they do not know when R2 returned to the facility. S2 stated that they were not aware that R2 was unable to leave the facility unassisted.

Staff Zanders provided LPA a copy of the incident report dated 7/1/22 which indicates that on 6/30/22 sometime during the day R2 left the facility and later that day R2's family member called and told S1 that R2 was at their girlfriends house. Staff Zanders called and spoke with R2 who indicated that they wanted to stay at their girlfriend's house until after the fourth of July. Staff Zanders stated that they explained to R2 that they are not able to leave the facility unattended and R2 stated "I know". Staff Zanders asked R2 for the address so they could take R2 back to the facility and R2 refused. Staff Zanders called the Police Department to inform them that R2 eloped from the facility on 6/30/22. Staff Zanders stated that R2 did not sustain any injuries when R2 was away from the facility.

On 7/13/22 Community Care Licensing (CCL) received an incident report from staff Zanders indicating that on 7/13/22 staff #1 (S1) asked staff Zanders if they had seen R1. Staff Zanders noted that they searched the facility and did not locate R1 in the facility so they ran outside and found R1 walking down the street.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221
VISIT DATE: 07/29/2022
NARRATIVE
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On 7/15/22 LPA Rosales spoke with staff Zanders regarding the 7/13/22 incident of R1. Staff stated that construction workers were going in and out of the facility and the alarms were going off alot. Staff stated that the workers are were being supervised by staff. Staff Zanders stated that S1 indicated that R1 was just there with them. Staff Zanders stated that R1 was found a house away with no injuries. Staff stated that they currently have R1 with a 1:1. Staff stated that the residents Service Coordinator is working with them to have the R1 transferred to another facility due to their change in condition.

A review R1's records starting at 12:29 pm revealed that R1 is not able to leave the facility unassisted. On 7/13/22 staff failed supervise R1 as R1 eloped from the facility. A review of R2's records starting at 3:10 pm revealed that R2 is not able to leave the facility unassisted. On 6/30/22 staff failed supervise R2 as R2 eloped from the facility. On 7/10/22 R2 again left the facility unassisted.

Due to time constraints LPA will need to return at a later date to continue the Post Licensing visit.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Civil penalties issued in the amounts of $250.00 and $250.00.

Exit interview conducted, todays reports, civil penalties, and appeals rights were reviewed and emailed to staff Zanders.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/29/2022 06:29 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/29/2022 at 05:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/30/2022
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
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Staff placed toxic items in an inaccessible location during facility visit. Staff will provide documentation of scheduled staff training to CCL by 7/30/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medications and toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.
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Request Denied
Type A
07/30/2022
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff locked room with razors and will provide documentation of tools inaccessible to residents to CCL by 7/30/22. Staff will provide documentation of scheduled staff training regarding 87705(f)(1) to CCL by 7/30/22.
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as razors and gardening tools were observed accessible to residents which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


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Document Has Been Signed on 07/29/2022 06:29 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/29/2022 at 05:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/30/2022
Section Cited
CCR
87464(f)(1)(c)

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87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement is not met as evidenced by:
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Staff stated that they provide documentation of scheduled staff training regarding elopement protocols to CCL by 7/30/22 and they will conduct a reappraisal for R1 and provide documentation of staff training and reappraisal to CCL 8/8/22.
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 and R2 left the facility unassisted which poses an immediate health and safety risk to persons in care.
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Deficiency Dismissed
Type B
08/05/2022
Section Cited
HSC1569.269(a)(2)

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1569.269 Enumerated rights; severability(a)(2) Residents of residential care facilities for the elderly shall have all of the following rights: To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone...
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Staff stated that they will contact the licensee regarding turning off the video cameras and will provide documenation that they have been turned off to CCL by 8/8/22.
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Based on LPA’s observations and record review, the licensee did not comply with the section cited above as LPA observed video cameras in the common areas of the facility which poses a potential personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2022 06:29 PM - It Cannot Be Edited


Created By: Joann Rosales On 07/29/2022 at 05:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GLEN PARK AT OJAI
FACILITY NUMBER: 565850221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/08/2022
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.


This requirement is not met as evidenced by:
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Staff stated that she will submit a building permit for the toilet and sink in the prior storage room and the wall placed in the medication room along with an updated facility sketch to CCL by 8/8/22
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Based on LPA's observations, the licensee did not comply with the section cited above as a toilet and sink was added to a storage room and a wall added to the medication room which poses a potential safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2022


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